Utilization Review (UR) is one of the most important parts of the workers’ compensation process in California, and like many legal topics, the terminology can be confusing to laypeople.
What exactly is Utilization Review (UR)?
The State of California defines UR as: “the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers’ compensation claims administrators are required by law to have a UR program. This program is used to decide whether or not to approve medical treatment recommended by a physician which must be based on the medical treatment guidelines.”
What does that mean for my claim?
It’s worth taking a look at the Division of Workers Compensation Fact Sheet on UR. One of the key takeaways is that when your doctor recommends treatment, the claims administrator has five days to review the UR. If the administrator needs additional information to make a decision, they can have up to 14 days. If 14 days passes and you, your doctor, or your attorney have not heard from the claims administrator, then the claims administrator cannot object to your doctor providing treatment.
What if the claims administrator objects to my claim?
In the event of a dispute, it’s imperative to respond quickly. Medical treatment disputes are resolved by physicians through an Independent Medical Review (IMR). If you need to initiate an IMR, you’ll want to review the State of California IMR FAQ.
The UR process is governed by the State of California. So, employers must respect the guidelines put in place by the State. Employers who don’t comply may face penalties.
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